3/20/2008 @ 6:00PM

Conflicted doctors

Brilliant doctors often work closely with big drug companies, and they seem to like their corporate partners just fine. Too fine, say their vocal critics–no doctor can have objective views about Lipitor when he takes
Pfizer
‘s money to develop or test it. But when the critics are doctors themselves, as they quite often are, keep in mind that there’s a deeper conflict in play here that the critics never acknowledge or discuss. By working at the cutting edge of pharmacology in close collaboration with Big Pharma, top-tier doctors are taking over the whole medical show. It’s because of their work that so many of their less able colleagues are destined to provide doc-in-a-box services at
Wal-Mart
, at cut-rate prices prescribed by Big Insurance or Big Government.

Great software programmers go to
Microsoft
,
Sony
, IBM and
Google
because that’s where their brilliant code gets assembled, compiled and dispatched to billions of desktops. Big Pharma is where the next Jenner, Pasteur or Salk goes to bottle his insight and expertise, and mass-produce it. Less celebrated but highly skilled clinicians at places like the Mayo Clinic conduct the painstaking trials required to satisfy the Food & Drug Administration that a drug is good to go. Other top-notch researchers at elite academic hospitals play central roles in finding new uses for already licensed drugs and developing cocktail therapies that often work far better than any single-drug alternative.

It’s nonsense to suggest that the honest medics could do all this in Pharma-free labs, funded by government or charitable foundations. A huge part of developing a new drug hinges on shotgun searches followed by countless rounds of tests and trials that screen tens of thousands of compounds and go on for decades. Work of this scope just can’t happen without the backing of Big Pharma’s billions. Academics working in pristine purity have their role, too, and many like to think they supply all the real genius. But on its own, their genius never gets anywhere close to a cvs store.

The Big-Pharmatization of medicine is great for medical specialists at the pinnacle of their profession. It lets them work on the most refractory problems in close collaboration with companies that are rich enough to fund the most ambitious and difficult work. It lets them turn theory, experiment, dedication and ambition into millions of lives saved and, now and again, a lot of cash, too. But step by step their work makes medicine a lot less challenging and financially rewarding for the rest of their medical colleagues. Big Pharma’s products aren’t just tools of the medical trade anymore–they’re competition.

In the old way of looking at things, drugs are just extensions of the physician’s wise hands, like stethoscopes and sutures. But when Big Pharma’s products get good enough, they displace a whole lot of hands-on doctoring. A pregnancy test used to be an office visit and a lab analysis; now it’s a remarkably smart dipstick sold over the counter. Diagnosis used to be almost all doctor; now it’s almost all lab–and the lab technicians rely on higher-caliber dipsticks, assays and reagents developed and mass-produced by the same teams of top-tier doctors, research hospitals and big drug companies.

When drugs get good enough, they displace hours of ineffectual (but remunerative) human monitoring and palliative care. Drugs displace doctors, nurses and hospital beds because they really work and because they often work long before bad chemistry morphs into clots, plaques, lumps and other symptoms that require scalpels and beds. In the first half of the 20th century almost all medically supplied gains in health and life expectancy came from germ-killing vaccines and antibiotics. All the important gains since have come from arrays of drugs that target clogged arteries, strokes, cancer and other diseases rooted in our own human chemistry. Human eyes can’t see and human hands can’t handle most of the things that make us sick–bacteria, viruses, white blood cells, antibodies, proteins, enzymes, fats and genes.

Most patients trust the white coat who prescribes Lipitor a lot more than the company that bottles it. It’s easy to resent a faceless corporation that charges $50 for a bottle of tiny pills and easy to like the kindly person with gentle hands who shares your worries, even though the visit costs more and does less. And politics being what they are, Washington is far happier bashing Big Pharma than bashing the Main Street doctor in Oshkosh. But when doctors join the bashing and denounce other doctors for joining the enemy, consider the possibility that doctors in bed with Big Pharma are mass-producing the genius that may be bad for other doctors but good for patients.

Peter Huber is a senior fellow of the Manhattan Institute and coauthor of The Bottomless Well (Basic Books, January 2005).